• Health Brigade Ryan White Referral Form

    This form is HIPAA compliant. You must send all required documentation along with the referral form to submit. The form will not let you submit without everything we need to process your referral. The referral is then sent through our approval process. If it is approved it can take up to two weeks for payment to be issued.
  • Section A: Type of Referral

    EFA only: You have a client at your agency who needs a one time rental/utility/hotel stay and are requesting payment assistance from Health Brigade. Full Client Referral: You have a client who does not currently have a RW case manager in the Richmond area who needs our full scope of services.
  • Referrals for EFA Assistance are currently closed.

    We will not be accepting any referrals for EFA assistance until April 1, 2023. Thank you.
  • Section B: Client's General Information

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  • Section C: Financial Request Information

    Applicant name must be on the lease or bill when requesting assistance.
  • Rental Assistance Information

    We are unable to pay for security deposits or costs associated with moving
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  • Utility Assistance Information

    We are currently able to pay up to $500 toward utility bills to prioritize funds
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  • Section D: Status Verification + Eligibility Docs

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  • Section E: Referring Agency Information

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